Health Care Department Operations Manual

Chapter 3 – Health Care Operations

Article 3.5 – Dental Care: Dental Clinic Operations

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3.3.5.13 Access to Dental Care

Policy
- The California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) shall ensure all patients are provided access to dental care by adhering to the requirements set forth in the CCR, Title 15, Division 3, Chapter 2, Subchapter 3, Article 6, Section 3999.367(a)(1), Dental Care. CCHCS, Adult Correctional Dental Care shall be responsible for developing policies and procedures that ensure all patients receive equal access to dental care.
Purpose
- To ensure that CDCR patients have timely and equal access to dental care by utilizing a system that provides guidelines enabling patients to receive dental care based on medical necessity.
Procedure Overview
- For the purpose of this policy, access to care means that a patient can be seen by a clinician in a timely manner, be given a professional clinical judgment and receive medically necessary care.
- The Dental Health Program Manager (DHPM) III shall ensure access to dental care for all patients by identifying and eliminating any unreasonable barriers that obstruct the availability of dental services.
- All patients shall be informed via the Patient Orientation to Health Care Services Handbook (Reference the Health Care Department Operations Manual [HCDOM], Section 3.3.2.13(c)(1)(A)) of the facility dental services available to them.
- All patients shall have equal access to dental services by:
  - Submitting a CDCR 7362, Health Care Services Request Form, requesting dental care for which ducated face-to-face triage encounters shall be scheduled to have specific complaints addressed.
    - The CDCR 7362 is a confidential health care document used to assess the priority of the request and to access the appropriate discipline or provider;
    - The CDCR 7362 shall be available to patients in the housing units, clinics, Reception Center and from health care staff;
    - Patients shall complete all pertinent information requested in Part I. at the top of the CDCR 7362, sign and date the form, and submit the request as outlined in Section (d)(1)(D); or (d)(2)(A).
  - Receiving unscheduled dental encounters for emergency and urgent Dental Priority Classification (DPC) 1 dental services.
  - Being referred by other health care providers, ancillary, and custodial staff.
  - Receiving a DPC based on clinical findings and radiographs. All patients shall be eligible to receive dental treatment based on their assigned DPC in accordance with the HCDOM, Section 3.3.5.3, Dental Priority Classification.
- Patients requiring special dental needs care shall have treatment initiated or scheduled regardless of time remaining on their sentence after meeting plaque index score eligibility requirements where applicable and pending approval by the Dental Authorization Review Committee.
Procedure
- General Requirements
  - Dental services shall be available at least eight hours per day, Monday through Friday, excluding holidays. Dental clinics shall operate until all authorized emergency, scheduled urgent care DPC 1 and ducated patients have been seen. (Reference Section (d)(4)(B)).
  - Patients shall initiate access to dental services utilizing the CDCR 7362 and may submit a CDCR 7362 at any time to request dental services.
  - If a patient is unable or refuses to complete a CDCR 7362, health care staff shall complete the form on behalf of the patient, documenting the complaint and the reason the patient did not personally complete the form. In this instance, the health care staff member completing the CDCR 7362 shall sign and date the form.
  - Special procedures shall be implemented to ensure that patients who have difficulty communicating (e.g., those with a mental illness, who are non-English proficient, developmentally disabled, low reading level, or hearing impaired) have equal access to dental services.
    - Translation services (including sign language) shall be available for patients, as necessary, via certified bilingual health care staff or by utilizing a certified interpretation service when bilingual health care staff is unavailable.
    - Each institution shall maintain a contract for certified interpretation services. (Reference the HCDOM, Section 3.3.5.5(c)(3)(B)).
  - The DHPM III shall make arrangements with the custody unit supervisor to have patients with emergent or urgent DPC 1 dental conditions, as determined by the dentist or health care provider, report to the clinic on their own or escorted to the dental clinic for evaluation.
    - If a patient is unable to walk, arrangements shall be made to have the patient transported to the dental clinic or Triage and Treatment Area (TTA) as appropriate.
    - The dentist shall see these patients upon their arrival at the clinic and provide necessary treatment.
  - In cases of dental emergencies, patients shall receive dental services without submitting a CDCR 7362. Patients may access emergency care by verbally notifying custody or health care staff. Patients with a life-threatening illness or injury shall receive immediate medical attention.
  - RDHs and (registered) Dental Assistants shall not make dental assessments exceeding their scope of license, training, or departmental policies.
- CDCR 7362 Collection, Review and Distribution
  - Each institution shall have at least one locked box on each yard or facility designated for patients to deposit CDCR 7362s.
  - Mondays through Fridays the following shall occur:
    - A health care staff member shall pick up the CDCR 7362s daily.
    - After returning the CDCR 7362s to the clinic, a Registered Nurse (RN) shall initial and date the request forms.
    - The CDCR 7362s shall be separated, distributed by service requested (e.g., medical, dental, or mental health) and forwarded to their respective areas for processing.
    - A dental staff member shall record each CDCR 7362 requesting dental services.
      - In the event a patient submits multiple CDCR 7362s within a relatively short time period, the requests may be combined and treated as one for the purpose of the paper review and face-to-face triage processes. During the face-to-face triage encounter, the dentist shall ensure that all of the different dental issues contained on all of the CDCR 7362s are addressed and that the patient receives treatment at that time if indicated or is scheduled appropriately for treatment of all of the different dental issues contained on all of the CDCR 7362s.
      - Patients who submit multiple requests for the same condition or complaint within a relatively short time period should be educated by dental staff on the counterproductive results of doing so.
        
        This information can also be disseminated to the patient population via the Incarcerated Persons Advisory Council.
    - With the exception of CDCR 7362s requesting a comprehensive dental examination, a dentist shall review, initial, date and indicate the Paper Review Code (PRC) on each CDCR 7362 within one business day of the dental clinic’s receipt of the CDCR 7362. In those instances when there is not a dentist in the clinic, the Supervising Dentist (SD) shall be notified to provide direction.
    - Dental staff shall not make entries in the Subjective, Objective, Assessment, Plan, Education format on the CDCR 7362.
    - Upon completing the paper review, the dentist shall notify the Office Technician (OT), or designated dental staff, to schedule the patient for an encounter based on the urgency of the request or as outlined in Section (d)(2)(B)8.c. through e.
      - Patients who indicate emergent or urgent dental needs (terms of distress such as pain, swelling, bleeding, infection, etc.) shall be assigned a PRC of 1 (or “Urgent”) and shall be seen for a face-to-face triage encounter within three business days of the dental clinic staff receiving the CDCR 7362.
      - All other patients shall be assigned a PRC of “Other” (or “Routine”) and shall be seen for a face-to-face triage encounter within 10 business days, after the receipt of the CDCR 7362 in the dental clinic.
    - Institutions shall also use the following process to manage patient requests via the CDCR 7362 that are assigned a PRC of “Other” (or “Routine”).
      - For patients who describe or indicate routine conditions on the CDCR 7362, (DPC 3 conditions as defined in the HCDOM, Section 3.3.5.3, Dental Priority Classification), the dentist may choose not to schedule the patient for a face-to-face triage.
      - The dentist or designee may choose to respond in writing (without performing a face-to-face triage) to patients who use the CDCR 7362 process to:
        
        Ask when they will receive their fillings/cleaning/denture or to see if they are on a list for treatment.
        
        Request an examination or provision of treatment for DPC 3 conditions from an established treatment plan.
      - Patients requesting to be seen for routine conditions (DPC 3 conditions as defined in the HCDOM, Section 3.3.5.3, Dental Priority Classification) and who do not have a treatment plan shall be scheduled for a comprehensive dental examination within 90 calendar days of the dental clinic receiving the CDCR 7362. When this timeframe is not achieved, the treating clinician shall document the reason in a clinical note in the Electronic Dental Record System (EDRS), in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.
      - Patients requesting to be seen for routine conditions (DPC 3 conditions as defined in the HCDOM, Section 3.3.5.3, Dental Priority Classification) and who have an established treatment plan but have not been scheduled for treatment (other than for procedures for which the patient has refused treatment) shall be scheduled for treatment accordingly.
      - If the patient is not to be scheduled for a face-to-face triage pursuant to the PRC timeframes as outlined in Section (d)(2)(B)7.a. and b., the dentist shall:
        
        Perform a review of the patient’s health record to determine if there are any conditions diagnosed that have not been treated.
        
        Have the OT, or designated dental staff, generate a written notification to inform the patient as follows:
        
        The dental department received the request they submitted.
        
        Where applicable, they have been or will be scheduled for an appointment.
        
        Of the dentist’s understanding of the nature of the patient’s request.
        
        Document in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid as follows:
        
        They reviewed the health record subsequent to receiving a CDCR 7362.
        
        The date and results of the health record review, including the patient’s current DPC.
        
        No face-to-face triage was necessary therefore a written response was sent.
        
        The rationale or justification for sending a written response.
      - The written notification shall be sent to the patient within ten business days of the dental clinic receiving the CDCR 7362 and distribution shall be accomplished as outlined in the HCDOM, Section 3.3.2.3(c)(1)(A)3.
    - Patients with dental emergencies during dental clinic operating hours shall be managed as outlined in the HCDOM, Section 3.3.5.9(c)(2). Patients with dental emergencies outside dental clinic operating hours shall be managed as outlined in the HCDOM, Section 3.3.5.9(c)(3).
  - On weekends and holidays the following shall occur:
    - The TTA RN shall:
      - Review each CDCR 7362 for medical, dental and mental health services.
      - Establish medical priorities on an emergent and non-emergent basis.
      - Refer accordingly to the appropriate health care staff.
    - If a dentist is not available, then the TTA RN shall contact the Dentist on Call.
  - Processing CDCR 7362s
    - CDCR 7362s that require a face-to-face triage encounter
      - When a patient submits a CDCR 7362 on their own, or a staff member submits one on behalf of the patient, dental staff shall follow the procedures outlined in Section (d)(2)(B)5. through 7. and shall process the CDCR 7362 in accordance with EDRS Workflow 1-2 and associated Front Office Job Aid.
      - If treatment is provided at the subsequent face-to-face triage encounter, or if treatment is not provided during the subsequent face-to-face triage encounter and the patient needs to be brought back for treatment, dental staff shall follow the procedures described in the HCDOM, Section 3.3.5.2(c)(2)(B) and (c)(3)(A).
        
        Close out the CDCR 7362 ensuring that the form is signed and dated by the dental provider. If there are multiple requests for the same chief complaint, all of the CDCR 7362s need to be signed and dated before being scanned. Documenting the time of signature on the form is not required.
        
        Ensure that the patient is given a copy or copies, as needed.
        
        Scan the completed CDCR 7362(s) into the EDRS Document Center.
    - CDCR 7362s requesting a comprehensive dental examination
      - When a patient submits a CDCR 7362 requesting a comprehensive dental examination, the OT, or designated dental staff, shall process the CDCR 7362 in accordance with EDRS Workflow 1-2 and associated Front Office Job Aid.
    - For CDCR 7362s to which the dentist chooses to respond in writing
      - When a patient submits a CDCR 7362 and the dentist chooses to respond in writing without performing a face-to-face triage encounter, the dentist shall:
      - Follow the procedures described in Section (d)(2)(B)8.e. through f.
      - Complete the CDCR 7362 by writing an appropriate comment on the form (e.g., “No face-to-face triage”), entering their name, title and institution at the bottom of the form then signing and dating it.
      - Notify the OT, or designated dental staff, to process the CDCR 7362 in accordance with EDRS Workflow 1-2 and associated Front Office Job Aid.
- Face-to-Face Triage and Limited Problem Focused Exam Encounters
  - Face-to-face triage and limited problem focused exam encounters shall be performed in order to assess and diagnose a patient’s chief complaint and to provide treatment if necessary.
    - If a patient is being seen for a face-to-face triage or limited problem focused exam encounter, the dentist shall address the patient’s chief complaint. During the encounter, the dentist shall document the condition(s) diagnosed for treatment as well as the proposed treatment on the Dentrix odontogram and the Progress Note panel, in accordance with EDRS Workflow 1-3 and associated Back Office Job Aid, regardless of whether treatment is provided that day or at a subsequent appointment.
    - If the dentist identifies other dental conditions about which the patient is not complaining but which need to be addressed in the future and the patient has not undergone a comprehensive dental examination, the dentist shall inform the patient of the dental conditions and advise them to submit a CDCR 7362 to request an examination. The dentist shall also document in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid, that the patient has undiagnosed dental conditions about which they have been informed and the patient was advised to submit a request for an examination.
  - A face-to-face triage encounter:
    - Shall be provided for patients who have submitted a CDCR 7362.
    - Is a planned encounter for which dental staff has issued a ducat to the patient.
  - A limited problem focused exam encounter:
    - Shall be provided for patients with a dental emergency:
      - That arrive unannounced to the dental clinic and there is no record of a recently submitted CDCR 7362 addressing the emergent condition.
      - Referred by health care or custody staff and there is no record of a recently submitted CDCR 7362 addressing the emergent condition.
    - Is an unplanned encounter for which dental staff has not issued a ducat to the patient.
  - Each patient presenting to the dental clinic for a face-to-face triage or limited problem focused exam for a stated dental emergency shall complete a CDCR 237-F, Dental Pain Profile, before the face-to-face triage or limited problem focused exam is performed.
    - The dentist shall review and sign the CDCR 237-F before completing the face-to-face triage or limited problem focused exam.
    - If a patient is unable or refuses to complete the CDCR 237-F, the dentist shall complete the form on behalf of the patient, documenting the complaint and the reason the patient did not personally complete the form.
  - For each patient seen for a face-to-face triage or limited problem focused exam encounter, the dentist or designee shall at minimum document the following information in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid:
    - Vital signs.
    - Health history review. (Reference the HCDOM, Section 3.3.6.1(c)(2)(E) of this policy).
    - Nature and history of the complaint or dental condition that triggered the face-to-face triage or limited problem focused exam encounter.
    - Physical findings.
    - Proposed treatment.
  - Once a dentist has completed the face-to-face triage or limited problem focused exam, every effort shall be made to provide dental treatment at the same encounter. Only if it is not appropriate or possible to provide treatment at the same encounter may a patient be scheduled for care within the timeframes indicated for their DPC. (Reference the HCDOM, Section 3.3.5.3(c)(5) and (6) as well as the HCDOM, Section 3.3.5.3, Appendix 1, Dental Priority Classification).
- Dental Encounters
  - Priority ducat lists for dental encounters shall be prepared and ducats generated and distributed as outlined in the HCDOM, Section 3.3.5.1(c)(1)(B).
  - Each patient requesting dental services shall be seen if they are ducated and arrive in a timely manner at the clinic for their scheduled encounter, unless the SD or designee cancels the encounter. (Reference the HCDOM, Section 3.3.5.1(c)(3) regarding encounters cancelled by dental staff).
  - If a patient fails to show for any dental encounter, then the dentist or designee shall follow the policy as outlined in the HCDOM, Section 3.3.5.1(c)(4).
  - In the event a dentist is unexpectedly absent and other dentists at the institution are unable to provide treatment for the patients scheduled in the clinic covered by the absent dentist, the scheduled encounters may be cancelled only with the approval of the SD or designee.
  - An inability to access the Electronic Health Record System or EDRS or any other clinical system (e.g., MiPACS) shall not preclude access to or the provision of dental care for patients. Dental staff shall implement downtime procedures when clinical documentation systems are not available.
- Required Staff Members for Patient Dental Encounters
  - For reasons of safety and security:
  - Patients in the dental clinic shall always be directly observed by at least one staff member at all times.
  - A minimum of two staff members (two dental staff or one dental staff and one Correctional Officer) shall be present in or have direct line of sight of the dental operatory when a patient is receiving treatment. Each staff member shall be present in or have direct line of sight of the dental operatory for the duration of the encounter.
- Patient Dental Encounters with Opposite Gender Dental Staff
  - Whenever possible, a staff member of the same gender as the patient shall be present in the dental operatory for the duration of the dental encounter and shall be identified by name and documented in a clinical note in the EDRS, in accordance with EDRS Workflow 1-2 and associated Back Office Job Aid.
- Lockdown or Modified Program
  - During a facility lockdown or modified program, dental staff shall coordinate with the clinic RN, patient appointment schedulers and custody staff to facilitate continuity of care.
  - A lockdown or modified program shall not prevent the completion of scheduled dental encounters, and custody personnel shall escort the patient to the dental clinic, subject to security concerns.
  - In facilities or housing units on modified program or lock down status, a system shall be maintained to provide patients access to health care services.
    - Access to health care services shall be accomplished via daily collection of CDCR 7362s and referral from other health care providers, ancillary staff, and custodial staff.
    - The health care staff shall refer all patients requiring emergent or urgent dental treatment to the dental clinic for evaluation and treatment.
  - Patients in Restricted Housing Units (RHU) (e.g., General Population RHU, Correctional Case Management System RHU, Enhanced Outpatient Program), shall have access to CDCR 7362s.
    - The patients shall be provided a method for depositing the CDCR 7362 in the locked box for daily pick up by health care staff in the RHU.
    - The RN shall refer all patients requiring emergent or urgent dental treatment to the dental clinic for evaluation and treatment.
  - Dental staff shall document occurrences of a lockdown or modified program preventing patient access to care. Dental staff shall report these occurrences to the DHPM III who shall inform the AW for Health Care Services, or Captain when there is no Health Care Services AW position allocated at the institution.
- Specialized Health Care Housing
  - When dental staff become aware that a patient has been admitted to a specialized health care housing unit, for dental related conditions, dental staff shall:
    - Provide a dental clinical evaluation within 24 hours during dental clinic operating hours.
      - Outside dental clinic operating hours, a dental consult may be initiated by the specialized health care housing unit admitting health care provider by contacting the Dentist on Call.
    - Participate in interdisciplinary grand rounds and assessments with frequency determined by the patient’s condition and setting.
  - Emergency, urgent, interceptive, routine, and special dental care shall be provided, determined by the patient’s condition, and consultation with relevant medical and mental health staff.
References
California Code of Regulations, Title 15, Division 3, Chapter 2, Subchapter 3, Article 6, Section 3999.367
Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.10, Specialized Health Care Housing
Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.2.3, Comprehensive Dental Examinations – Mainline Facility
Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.2.13, Facility Level Dental Health Orientation and Self-Care
Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.5.1, Priority Health Care Services Ducat Utilization
Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.5.2, Recording and Scheduling Dental Encounters
Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.5.3, Dental Priority Classification
Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.5.5, Interpreter Services
Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.5.9, Dental Emergencies
Health Care Department Operations Manual, Chapter 3, Article 3, Section 3.3.6.1, Health Records Organization and Maintenance
California Correctional Health Care Services, Patient Orientation to Health Care Services Handbook
Revision History
- Effective: 04/2006
  Revised: 03/2019, 11/2020, 02/2022, 10/21/2024